Pleural effusion is a common expected finding in patients who have congestive heart failure, but these sedentary patients are also at risk for pulmonary embolism and, rarely, may develop a postmyocardial infarction or Dressler syndrome. Pleural effusions and atelectasis are also common in the coronary care setting. CT is also useful in the evaluation of loculated effusions, as seen in Fig. CT scans of patients from the intensive care unit often reveal unexpected or larger than expected pleural fluid collections.
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In contrast, small pleural effusions are often missed or underestimated on the supine portable radiograph. Very large pleural effusions are a cause of compressive atelectasis and may even completely collapse a lung, with a contralateral shift of the mediastinum (see Fig 4.5). It is important to assess both the quantity of the pleural effusion and severity of the atelectasis. Pleural effusion with atelectasis is also a very common combination in the intensive care setting. Pulmonary embolism should be strongly suspected when a patient on bed rest develops dyspnea, hemoptysis, chest pain, or thrombophlebitis. Late development or increasing pleural effusion could be secondary to postpericardiotomy syndrome or pulmonary embolism. In the previously noted clinical settings, the timing of the developing effusion should be considered. Obviously, a thoracotomy explains effusion, and sympathetic effusion related to abdominal surgery is a well-known entity.
The postoperative patient requires the most careful consideration because subsegmental atelectasis is extremely common and is frequently secondary to a combination of thoracic splinting and small airway mucous plugs, but the coexistence of pleural effusions requires a separate explanation. This combination is common and requires especially careful correlation with the clinical data. Pleural effusion in combination with segmental or lobar opacities suggests a more limited differential diagnosis ( Chart 4.3). Reed MD, in Chest Radiology (Seventh Edition), 2019 Pleural Effusion with Segmental and Lobar Opacities